EDUCATION EDGE JOB SHADOWING
Medical Authorization Form
MEDICAL AUTHORIZATION
Should it be necessary for my child to have medical treatment while
participating in Job Shadowing, I hereby give the school district personnel
or the below named company permission to use their best judgment in
obtaining medical services for my child, and I give permission to the
physician selected by school district personnel or the company to render
whatever medical treatment he or she deems necessary and appropriate.
Permission is also granted to release necessary emergency contact/medical
history to the attending physician, the school system, or to the host
company, if needed.
Company Name: __________________________________
Job Shadow Date: May 12, 2010
Name of Workplace Host:__________________________
Student's Name:_________________________________________________________
Date of Birth:____________________________________________________________
Address:______________________________________________________________
Home Phone:___________________________________________________________
Daytime phone contact information for parent(s) or guardian: ________________
Contact other than parent/guardian: _____________________
Relation to Student:____________________________Phone:____________________
Family Doctor:________________________________Phone:_____________________
Preferred Hospital:_______________________________________________________
Hospital Address:________________________________________________________
Hospital Phone:__________________________________________________________
Does your child require any special accommodations due to medical
limitations, disability, dietary constraints, or other restrictions? If yes,
please explain.
______________________________________________________________________
______________________________________________________________________
I hereby agree to all of the above authorizations and permissions.
______________________________________________________
Signature of Parent/Guardian
